Ýzole koroner arter baypas greft cerrahisi sonrasý geliþen mediastinit olgularýnýn deðerlendirilmesi: Tek merkez deneyimimiz

AMAÇ: Bu çalýþmada median sternotomi ile yapýlan izole koroner arter baypas greft cerrahisinden sonra geliþen mediastinit olgularýnýn, etken olan mikroorganizmalarýný, risk faktörlerini ve klinik özelliklerini ortaya koymak amacýyla deðerlendirilmesi amaçlanmýþtýr.
GEREÇ VE YÖNTEM: Mart 2009–Aralýk 2018 tarihleri arasýnda kalp ve damar cerrahisi kliniðinde median sternotomi ile izole koroner arter baypas greft cerrahisi yapýlan ve ameliyat sonrasý dönemde mediastinit geliþen toplam 44 hasta (32 erkek, 12 kadýn; ort. yaþ 62.84±6.951 yýl; daðýlým 46–78 yýl) çalýþmaya alýndý. Hastalarýn demografik özellikleri, eþlik eden hastalýklarý, alýþkanlýklarý, operasyon öncesi yatýþ süreleri, elektif veya acil cerrahi durumlarý, perioperatif internal mammarian arter kullanýmlarý, perioperatif kan ve kan ürünü transfüzyonu, operasyon ve kardiyopulmoner baypas süreleri, antibiyotik profilaksilerinin uygunluðu, týbbi ve cerrahi tedavileri, klinik bulgular ve laboratuvar sonuçlarý dahil olmak üzere veriler geriye dönük olarak incelendi. Pürülan akýntý kültürü cerrahi alandan veya cerrahi onarým yapýldýðý zaman doðrudan mediastinal boþluktan alýndý, elde edilen materyalden yapýlmýþ olan mikrobiyolojik inceleme kaydedildi.
BULGULAR: Yaklaþýk 10 yýllýk bir periyotta yapýlan izole koroner arter baypas greft cerrahisinden sonra geliþen mediastinit oraný %1 olarak belirlendi. Mediastinit geliþen hastalarda geliþmeyenlere göre yaþ, cinsiyet, sigara kullanýmý, operasyon ve kardiyopulmoner baypas süresi ve perioperatif kan transfüzyonu açýsýndan istatistiksel olarak anlamlý fark saptanmadý. Diabetes mellitus varlýðý ve ortalama vücut kitle indeks’inin yüksekliði mediastinit geliþen hastalarda geliþmeyenlere göre anlamlý bulundu. Mediastinit tanýsý hastalarýn 38’ine (%86.3) ilk bir ayda, beþine (%11.3) ilk üç ayda, birine (%2.2) ise ilk bir yýlda konulmuþtur. Pürülan akýntý kültürlerinde üreyen mikroorganizmalarýn 25’ini (%56.9) Gram pozitif bakteriler, on üçünü (%29.6) Gram negatif bakteriler ve birini (%2.3) mantarlar oluþturmuþtur. Beþ (%11.4) olguda ise patojen mikroorganizma üretilemedi. En sýk izole edilen üç etken metisiline rezistan koagülaz negatif stafilokoklar (MRKNS) (%50), Escherichia coli (%9.1) ve Klebsiella pneumoniae (%6.8) idi.
TARTIÞMA: Kardiyovasküler cerrahi giriþim geçiren hastalarda özellikle cerrahi alan enfeksiyonuna dikkat edilmelidir. Taburcu olduktan sonraki takip önemlidir ve enfeksiyon ortaya çýktýðýnda ampirik tedavi yaklaþýmý hastanemizde önde gelen enfeksiyöz ajanýn MRKNS olduðu dikkate alýnarak belirlenmelidir.

Evaluation of post-operative development of mediastinitis in patients undergoing isolated coronary artery bypass grafting surgery: A single-center experience

BACKGROUND: In this study, we aimed to evaluate mediastinitis cases developed after isolated coronary artery bypass graft surgery performed by median sternotomy to determine the causative microorganisms, risk factors, and clinical features.
METHODS: Between March 2009 and December 2018, a total of 44 patients (32 males and 12 females; mean age 62.84±6.951 years; range, 46–78 years) who underwent isolated coronary artery bypass grafting surgery with median sternotomy and developed mediastinitis postoperatively were included in the studying our cardiovascular surgery (CVS) department. Patients demographic information, comorbidities, habits, pre-operative hospital stay, elective or emergency surgery, perioperative internal mammary artery use, perioperative blood or blood product, operation and cardiopulmonary bypass times, suitability of antibiotic prophylaxis, medical and surgical treatment, clinical data, and laboratory results were retrospectively analyzed. Purulent discharge cultures obtained directly from the mediastinal space and microbiological examination notes made from the material obtained from the surgical site or surgical repair were recorded.
RESULTS: In isolated coronary artery bypass grafting surgery performed over a period of approximately 10 years, the rate of mediastinitis was 1%. There was no statistically significant difference between patients with and without mediastinitis in terms of age, sex, smoking habits, duration of operation and cardiopulmonary bypass, and intraoperative blood transfusion. The presence of diabetes mellitus and high mean body mass index was significantly higher in patients with mediastinitis compared to those without. Mediastinitis was diagnosed in 38 (86.3%) patients in the 1st month, 5 (11.3%) in the first 3 months, and 1 (2.2%) in the 1st year. Twenty-five (56.9%) Gram-positive bacteria, 13 (29.6%) Gram-negative bacteria, and 1 (2.3%) fungi were the microorganisms grown in purulent discharge cultures. Pathogen microorganisms could not be produced in 5 (11.4%) cases. The three most commonly isolated agents were methicillin-resistant coagulase-negative staphylococci (MRCNS) (50%), Escherichia coli (9.1%), and Klebsiella pneumoniae (6.8%).
CONCLUSION: Attention should be paid to surgical site infection in patients undergoing CVS. Following discharge, follow-up is important and empirical treatment should be determined by considering the presence of MRCNS as the leading infectious agent in our hospital when infection occurs.